Long-term efficacy of combined phacoemulsification plus trabeculectomy versus phacoemulsification plus excimer laser trabeculotomy

Abstract

Combined cataract and glaucoma procedures, and minimally-invasive glaucoma surgery in particular, have gained increasing interest over the past few years. The aim of this study was to compare the long-term efficacy of combined phaco-trabeculectomy (Phaco-Trab) and combined phacoemulsification plus excimer laser trabeculotomy (Phaco-ELT). Retrospective, non-randomised, comparative, interventional case series of consecutive patients after Phaco-Trab and Phaco-ELT at the University Hospital of Zurich and the Talacker Eye Center Zurich in Switzerland. Inclusion criteria were diagnosis of glaucoma plus vision-impairing coexisting cataract. Primary outcome measures were change in intraocular pressure (IOP), number of anti-glaucoma drugs (AGDs), and best-corrected visual acuity (BCVA) 1 year and 4 years after the procedure. Secondary outcome measures were surgical complications and requirement of postoperative interventions. Success was defined based on the criteria of the Tube-versus-Trabeculectomy study. Mean age was 76.1 ± 8.6 years (29.2 % males; 47.8 % right eyes). Phaco-Trab (n = 62) decreased median IOP from 22.8 to 13.0 at 1 year and to 14.0 mmHg at 4 years. AGDs were reduced from 2 drugs to 0 AGDs at 1 year and 4 years. Median BCVA improved from 0.2 logMAR to 0.0 logMAR at 1 year and 4 years. Phaco-ELT (n = 51) lowered median IOP from 19.0 to 15.0 at 1 year and to 14.0 mmHg (p = 0.002) at 4 years. AGDs were reduced from 2 drugs to 1 AGD at 1 year and 4 years (p = 0.002). BCVA improved from 0.4 logMAR to 0.1 logMAR after 1 year and 4 years. If not stated otherwise, all changes compared to baseline were highly significant (p < 0.001). No perioperative complications occurred; postoperative interventions were performed in 74 % of Phaco-Trab patients. Both surgical procedures reduced IOP and AGDs and improved BCVA significantly and persistently during the entire follow-up period of 4 years with a good safety profile. This study validates Phaco-ELT as an option when post-operative target pressure in the mid-teens would be adequate, whereas Phaco-Trab would be the treatment of choice when IOP in the low teens is desired.

The AIDA and the extra laser systems for excimer laser trabeculotomy proved comparable IOP lowering efficacy—12-month results

“…Our results confirm the outcome of previous studies [13,14,18] and prove a significant reduction in IOP and AGD comparable with the studies mentioned above. The higher IOP reduction in the ExTra group compared to the AIDA group can be explained by the higher baseline IOP in the ExTra group; the IOP lowering potency of ELT depending on baseline IOP was previously described by Töteberg et al [14].…”

“…Furthermore, ELT can be offered as a therapy for phacic patients who are scheduled for cataract surgery to reduce IOP and reduce the need for topical medications. Previous studies proved an IOP lowering efficacy of combined phaco-ELT which exceeds the efficacy of phaco alone [13][14][15][16][17][18][19][20][21][22][23]26]. use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.…”

“…The following findings on cataract surgery combined with excimer laser trabeculotomy (phaco-ELT) have been published thus far: (1) ELT and phaco-ELT effectively lowers IOP and reduces the need for topical anti-glaucoma drugs (AGD), (2) ELT is more effective when combined with cataract surgery, (3) phaco-ELT lowers IOP more effectively in higher baseline IOP, however, (4) even when baseline IOP is ≤ 21 mmHg phaco-ELT still lowers IOP, and (5) phaco-ELT can lower IOP for a long period of time, i.e., up to 4 years [13][14][15][16][17][18][20][21][22][23]. All of these findings are based on studies which have used the AIDA laser system.…”

Long-term treatment success and safety of combined phacoemulsification plus excimer laser trabeculostomy: an 8-year follow-up study

“…A single-use fiber optical laser probe is inserted into the anterior chamber through a limbal paracentesis [22,23,26]. Under gonioscopy, ten laser channels are created through the juxtacanalicular trabecular meshwork and the inner wall of Schlemm's canal, thereby enhancing the outflow of aqueous humor [22,[26][27][28][29]. Unlike other laser-based techniques, i.e., argon laser trabeculoplasty or trabecular meshwork-based MIGS procedures that also seek to remove juxtacanalicular trabecular meshwork and the inner wall of Schlemm's canal, e.g., trabeculotomy ab interno using Trabectome, ELT produces scant collateral damage at the periphery of the ablation zone, which prevents a massive inflammatory reaction and thus leads to less scar tissue formation [30,31].…”

Selective laser trabeculoplasty following failed combined phacoemulsification cataract extraction and excimer laser trabeculotomy can control intraocular pressure for a limited time

“…As the prevalence of glaucoma rises with age [1] and, thus, coexisting cataract is commonly observed, trabeculectomy combined with phacoemulsification cataract extraction has become an option in the armamentarium of surgical glaucoma management [8][9][10]. However, trabeculectomy combined with cataract surgery poses significant risks for the patient, such as hypotony and infections, i.e., blebitis with or without endophthalmitis [11,12]. Throughout previous decades, various surgical procedures with a moderate efficacy and a more favorable safety profile compared to trabeculectomy have evolved and proven to be effective in lowering IOP, i.e., micro-invasive glaucoma surgery (MIGS) procedures.…”